Healthcare Provider Details

I. General information

NPI: 1164302410
Provider Name (Legal Business Name): ALISSA MCCULLOUGH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 10/24/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 16TH ST
SANTA MONICA CA
90404-1249
US

IV. Provider business mailing address

410 E SYCAMORE AVE
EL SEGUNDO CA
90245-2434
US

V. Phone/Fax

Practice location:
  • Phone: 424-259-9620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number810558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: